Healthcare Provider Details

I. General information

NPI: 1043654247
Provider Name (Legal Business Name): WYCLIFFE OPII
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2013
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 S LIMESTONE 304B CHARLES T. WETHINGTON BUILDING
LEXINGTON KY
40536-0200
US

IV. Provider business mailing address

900 S LIMESTONE 304B CHARLES T. WETHINGTON BUILDING
LEXINGTON KY
40536-0200
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-9918
  • Fax: 859-323-1197
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR3292
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: